Consent Form: Meningococcal Group ACWY Vaccine and Tetanus, Diphtheria/Inactivated Polio Vaccine (Td/IPV)

Student First Name	Student Surname		Ethnicity	Date of Birth
Home Address       Postcode		Daytime Contact Telephone Number   1.   2.
School and Year Group		GP/Doctor’s Surgery

Please COMPLETE fully and SIGN the consent box below
Must be completed by Parent or Legal Guardian only

I give consent for my child to receive the following immunisations
Meningococcal group ACWY	YES         NO        Circle  as appropriate	Signature       (Must be signed by Parent or Legal guardian)	Relationship to Student
Tetanus, Diphtheria and Polio (Td/IPV)	YES     NO        Circle  as appropriate	Name (Print)	Date

Please complete the important health questions below

	Yes (Please give details/dates)	No
Does your child have any medical problems?
Is your child taking any regular medication?
Does your child have any severe allergies?
Has your child ever had a reaction to previous vaccinations?
Has your child received the Meningococcal ACWY immunisation at your GP Surgery/Travel Clinic in the last 4 years (Note: This does not include the Meningitis C only vaccine)
Has your child received the Tetanus/Diphtheria/Polio vaccination in the last 5 years at your GP surgery or in A&E/Hospital?

 For office use only:

Vaccine	Date/Time	Site of 0.5ml IM injection		Batch No/Expiry	Signature	Print name
Meningococcal Group  ACWY		L Delt	R Delt
Td/IPV		L Delt	R Delt

Thank you for completing this form, please return completed to school immediately.

All forms must be returned

Privacy statement

This service is provided by Sirona care & health, as part of the Community Children’s Health Partnership (CCHP).

Keeping your personal information safe and secure is important to us – so we’ve updated our privacy notice to reflect the changes in data protection laws.

If you have any queries about how your personal information is used or your rights, please contact our Data Protection Officer:

Email: Telephone: Post:

sirona.dataprotectionofficer@nhs.net 0300 124 5403 Data Protection Officer, Sirona care & health,  2nd Floor, Kingswood Civic Centre, High Street, Kingswood, Bristol, BS15 9TR

 

For office use only

 

IMMUNISATION CHECKLIST	YES                                                                    NO
Details correct on consent form/consent given?
Well today?
Any medical problems?
Any medication/treatment?
Any known allergies?
Any reactions to previous vaccinations?
Any possibility of pregnancy?
Checked on CHIS list?
Advice on possible side effects and their management?
Advice sheet given?

 

Pupil Consent: The immunisation check list has been discussed with me and I consent to this immunisation.
MenACWY	Pupil Signature and date:	Td/IPV	Pupil Signature and date: